Provider Demographics
NPI:1053035477
Name:PENA, DIANA R (PMHNP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:R
Last Name:PENA
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:R
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20132 LANARK ST
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-1836
Mailing Address - Country:US
Mailing Address - Phone:386-216-6302
Mailing Address - Fax:
Practice Address - Street 1:20132 LANARK ST
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:CA
Practice Address - Zip Code:91306-1836
Practice Address - Country:US
Practice Address - Phone:386-216-6302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022827363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health